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( / SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> • SERVICE REQUEST <br /> Type of Business or Prop FACILITY ID# SERVICE REQUEST# <br /> OWNER/Op RATOR <br /> q�u,� , CHECK If BILLINGADDRESS� <br /> FACILITY VE �r� <br /> J W T L tti� <br /> SITE ADDRESS Sz/ <br /> q• ` Sbee<Number Direction G ` Street Nameto <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / � <br /> (2-0 ZZ �" Street Number S[reet Name <br /> CIN STAT zip 2— <br /> PHONE# <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> -o av - aid <br /> PHONE#2 EM BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � /,�Z 4 r- CHECK If BILLING ADDRESS <br /> BUSINESS NAME /lam/` C PNON # 'L�� F EXT. <br /> HOME or MAILING ADDRESS Cwt' FAX# / <br /> 00 1 —Z777 <br /> CITY / �1) STAT zip 215-216 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT'hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA' a d FEDERAL-laws. - <br /> APPLICANT'S SIGNATURE: DATE; <br /> 1�— � 5 <br /> PROPERTY/BUSINESS OWNER❑ OTO /MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the &L,:LMG AR7T proof of authorization 5-o sign is required Title <br /> AUTHORIZATION TO RELEASE ATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environrnental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ts� <br /> COMMENTS' <br /> I <br /> y eof �7T�✓ ttiSf�cTirt/ �Te7� c c, �lrFi}CyE T3versr�ly , Z. <br /> y�l PAYMENT <br /> RECEIVED <br /> h �'� PzT� srsr�•y. o�e ss� SEP - 1 2009 <br /> ACCEPTS Y: EMPLOYEE#: 3e� DATE E�oAOm Coy <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: .ob PfE: �2, <br /> Fee Amount: Amount Paid Payment Date �/ <br /> Payment Type Invoice# Check# Received Ely- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />